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PLB. 68 DEPARTMENT OF HEALTH AND SOCIAL SERVICES <br /> Division of Health 43600 <br /> FEE $1.00 P.O.Box 309 N0. <br /> (I Permit per Tank) Madison,Wisconsin 53701 <br /> Date Issued ( <br /> Tank Size 1200 gal. STATE SEPTIC TANK PERMIT <br /> Copies: <br /> Private Res. This permit is for purchase of septic tank only and does (White)-Property Owner <br /> not exempt installation from state or local approval (Pink)-Tank Retailer <br /> (Blue)-Division of Health <br /> Public and/or permits. (Canary)-Issuing Agent <br /> Owner's Name Owner's Address <br /> *==I W1 54M <br /> Location (Legal Description) of Property Where Tank Will be Installed County <br /> Plumbers arae License No. Address <br /> RCUE=K HOPI M NFRU 03059 "SM9 W1 AM <br /> Signature of Person Obtaining Permit Address if Other Than Owner <br /> WHIPMeWI <br /> Address of Issuing Agent (Town, Village,City) County <br /> SL" <br /> Title: Signature <br /> i <br /> ZEJ= <br />